The Nurse Is Assessing the Surgical Dressing of a Patient

The nurse is assessing the surgical dressing of a patient who arrived on the unit an hour ago. The surgical dressing has serosanguineous drainage on the dressing. The nurse should:

A) make a note of the drainage on the worksheet to report it at the end of shift.
B) change the surgical dressing immediately to prevent infection.
C) outline the area of drainage with a pen and mark it with the date and time.
D) reinforce the dressing with clean gauze sponges and tape.